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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 k PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 0 13 IVY Job Address -�� V1— City { 1 f � Lot Size PM Owner ame "f` 1�c[�J Address Phone Contractors" Address License No. Phone s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ $ PUMP INSTALLATION ❑ 'SYSTEM REPAIR LJ if. ,,, �, OTHER ❑ � DISTANCE TO"NEAREST:-SEPTIC-TANK-1--SEWER•L'INES 14 -`'r'!!,` ^"'DISPOSAL FLD. PROP'LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF—WILL-......_PROBLEM AREA--CONSTRUCTION"SPECIFICATIONS ❑ industrial, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L1 Tracy41Nw of Casing Specifications ❑ Public ❑ Other SCI-Delta----""Depth of-Gr`out Seal Type of Grout j ❑ Irrigation --Approx. Depth, ❑ Eastern Surface Seal Installed by 6 Repair Work Done ❑ Type of Pump F H P� State Work Done Well Destruction EDme Well Diaier1f. _ ealing`,Materal (top 501 Depth Filler-Material {Below.601 LLYY TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` max.- mmercial_____ Other- Number available within 200 feet.) } S 1 €! Installation will serve: Residence { coer. f" Number of living units:�._ Number off bedrooms � E Character of soil to a`depth,of-3"feet: ('&INA JIL Water table depth SEPTIC TANK )❑ Type/Mfg 0.15 TCapacity a No. Compartments PKG. TREATMENT PLT. 0 Method of�Diirysal�/ i Distance toi nearest: Well Foundation Property Line 3 a f LEACHING LINE 9ANO.;& Length of;lines ),nd f Toil length/size ` FILTER BED CI Distance to nearest:_ Well, '�_Foundation.... -5— Property Line 67 SEEPAGE_ PITS ❑ Depth h Size Number l SUMPS ❑ Distance'do-nearest: Well Foundation Property Line r{ DISPOSAL PONDS ElI J�`,� N I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 7 rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." � The applicant must call for all re ired inspections. Complete drawing on reverse side. Signed #+ Title: flao4 t Date: FOR DEPARTMENT USE ONLY // 2 Application Accepted by Date / a9rr" Area0 ' Pit or Grout Inspection by Date`•"""""'"'"""`""" Ficial Inspection by ,'"' DateZ2� Additional Comments; ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 El Tracy 835-6386 Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { . F FEE AMOUNT DUE i AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO A. CASH + EH 1428 9 EH 13-24 MEV.I R 5) 1/ 7— �' © � 1 i5 b